Medical Transcription: Psychiatric Assessment

When you begin work as a medical transcriptionist, you should understand what a psychiatric assessment is and how to transcribe one. A full psychiatric evaluation is performed when someone is admitted to a hospital or outpatient mental health program and again on discharge.

They’re also frequently prepared by psychiatrists and psychologists when taking on a new patient. The examiner asks a lot of personal questions and weaves the answers into a comprehensive report that is drawn on to develop a treatment plan and referred to on future visits.

A psychiatric assessment is likely to land in your job queue in the form of a consultation report or discharge summary. A report that incorporates input from family members and others in the patient’s social circle (often referred to as informants) can go on for pages. When the only information source is an uncooperative or incapable patient, you’ll have a lot less to transcribe. Topics commonly covered include

Reason for current admission/referral

Previous psychiatric history

Substance abuse concerns

Family and personal social history

Medical status, including any physical ailments and current medications

Current mental status, as assessed by the examiner

Psychiatric diagnoses or possible diagnoses

Much of the information in a psychiatric evaluation is obtained by questioning the patient or through the examiner’s observations. When practical, family members and significant others may be interviewed as well.

Presenting problem

The first thing a psych report does is address the question: Why is the patient here today? It’s not unusual for the practitioner and the patient to provide different answers! If the answer contains words stated verbatim from the patient or another informant, they should be placed in quotes.

In a consultation report, the heading is typically Reason for Referral. In a hospital or clinic, it may be History of Present Illness or Reason for Consultation. Chief Complaint is also an option.

REASON FOR CONSULTATION

Dr. X, the patient’s primary care provider, referred her to me for evaluation and treatment of anxiety.

PRESENTING PROBLEM

“I’m so stressed out that I dread getting up in the morning.”

The presenting problem in a hospital report is likely to be more dramatic:

HISTORY OF PRESENT ILLNESS

The patient is a 42-year-old female who was found wandering around the mall parking lot and appeared intoxicated. According to police, she kept asking shoppers to help her “get the chickens out of my pockets.” She was brought to the ER by EMS.

CHIEF COMPLAINT

“Why am I here?”

The presenting problem, or case introduction, is often much longer than these examples.

Past psychiatric history

This section reviews any previous mental health treatment or diagnoses the patient has received. This, again, can be quite long:

PAST PSYCHIATRIC HISTORY

The patient was first hospitalized at 14 years of age. This is his 5th hospitalization. The first one occurred when. . . .

Or extremely brief:

PAST PYCHIATRIC HISTORY: Denied.

Substance abuse

This section relays details of the patient’s substance use or abuse, as self-reported and per past medical records. The title may vary, but the meaning is clear:

ALCOHOL AND DRUGS

The patient admits to marijuana use in the past but not currently, denies alcohol or tobacco. No history of treatment for alcohol or drug problems.

SUBSTANCE ABUSE: Denies.

Past medical history

Any significant or ongoing medical conditions or surgeries are listed here. There’s no need to number them unless the dictator does.

Family history

Mental health issues of immediate relatives, such as parents, siblings, and children, are described here. This tends to stick to mental health history: things like suicide, schizophrenia, alcoholism, or Alzheimer’s. If potentially relevant family medical issues exist, they’re often placed under a separate heading.

FAMILY PSYCHIATRIC HISTORY

Her mother has depression. Her son has ADHD. No known family history of suicidal attempts or completions. No history of drug or alcohol issues in the family.

FAMILY MEDICAL HISTORY

Her mother has migraines. There is diabetes on both sides of the family.

Social history

Pretty much anything is fair game in this section. It typically starts out with demographic information about the patient’s circumstances of birth and then progresses chronologically to the patient’s current living situation.

Relationships, children, deaths, relocation, and traumatic occurrences are described. The patient’s level of educational and work history often are mentioned. If the patient has legal issues, such as a child custody dispute or criminal charges or convictions, they may be listed here as well.

SOCIAL HISTORY

The patient is single, never married. He has a 4-year-old daughter living in Texas, which he admits makes him sad. He is a high school graduate. He works at an automobile dealership as a service manager. He says his job is very stressful and he is constantly worried about losing it. He is estranged from his family of origin and has little social support. No current unresolved legal problems.

Current medications

If the patient regularly takes medications, they’ll be listed here. This section may be dictated as a numbered list or strung together in a paragraph. If the dictator numbers them, list the medications vertically with a period at the end of each line.

CURRENT MEDICATIONS

1. Lexapro 10 mg per day.

2. Valtrex 500 mg per day.

Mental status examination

The mental status examination (MSE) assesses the patient’s current mental state. It describes the patient’s appearance, attitude, behavior, mood, thought process, and other aspects of her current condition.

Dictators tend to stick to favorite phrases, making them good candidates for entry into your word expander.

MENTAL STATUS EXAM

Adult female appears stated age, cooperative, noted to have some scars on her right forearm, disheveled, not in any acute distress or anxiety. Speech is appropriate, able to engage adequately in conversation, denies any auditory or visual hallucination, denies any suicidal or homicidal ideation, thoughts, plans, or gestures. Mood: She reports as depressed. Affect: Constricted. Insight and judgment are poor.

Diagnoses

Psychiatric diagnoses are expressed using a format that is distinct from all other medical diagnoses lists. They are organized into a five-part structure called a multi-axial system. Each axis covers a different aspect of the patient’s condition and can include multiple items. The axis number is expressed using Roman numerals. The dictator will state the axis number and the diagnoses associated with it, resulting in a structure like this:

DIAGNOSES

Axis I

1. Schizoaffective disorder, bipolar type.

2. Rule out depression.

Axis II

Deferred.

Axis III

Upper respiratory infection.

Axis IV

Financial pressures.

Axis V

GAF is 50.

The axis number and heading may be written on the same line or on separate lines, per facility preference. When on the same line, the text should be separated from the subheading by a tab, in a format similar to this:

PROVISIONAL DIAGNOSES

Axis I: Mood disorder, NOS; generalized anxiety disorder.

Axis II: Deferred.

Axis III: Hypothyroidism. History of low vitamin D.

Axis IV: Good social support.

Axis V: Current GAF 25.

Psychiatric diagnoses use very specific wording that comes from the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. Extra letters may be tacked on the end, such as R for revised edition or TR for text revision, as in the following examples:

DSM-III-R

DSM-IV

DSM-IV-TR

Treatment plan

The final section lays out the next steps for the patient, such as hospital admission, medication changes, or follow-up appointments.

TREATMENT PLAN: She will be admitted to the inpatient psychiatric unit under the care of Dr. Jones and placed on suicide precautions. Her current medications will be continued for now.

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